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PSYCHOSIS INTERMITTENT HYPONATREMIA, AND POLYDIPSIA SYNDROME
นพ. วญิญู ชะนะกลุสถาบนัจติเวชศาสตรส์มเด็จเจา้พระยา
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Outline
Definition Prevalence Etiology Diagnosis Management
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Definition
Polydipsia Primary /psychogenic polydipsia Secondary------DI,DM,medications
Hyponatremia
Water intoxication
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Hyponatremia
Plasma Na+ below 135 mMol/L
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Water intoxication
= SYMPTOMATIC HYPONATREMIA
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Water intoxication
Diarrhea-------hypotonic rehydration Marathon runners Drinking contest Iatrogenic PIP
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polydipsia
hyponatremia
Water intoxication
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Psychosis intermittent hyponatremia, and polydipsia syndrome
Compulsive water drinking Psychogenic polydipsia Self-induced water intoxication Without any organic disease Normal renal function
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Prevalence
3-40 % in chronic psychiatric inpatients
80 % are schizophrenia 10 % are organic mental disorder 5 % had episodes of water
intoxication
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Normal adaptaion
Thirst center
AVP (ADH)
Brain volume regulation
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Etiology
Hypothalamic defect Abnormal regulation of thirst +- SIADH
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Associated factors Male gender Caucasian Schizophrenia /mental retardation Chronicity of psychiatric disorder Negative symptoms Disorganized symptoms General symptoms of psychopathology Smoking
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Risk of water intoxication in polydipsic patients Rapidity
Severity
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Pathophysiology
Polydipsia Decrease plasma osmolality ECF ICF Brain edema Brain herniation
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Abnormal adaptaion
Thirst center
+- AVP (ADH)
Brain volume regulation
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Signs and symptoms
Simple polydipsia with polyuria water seeking behavior
Polydipsia with water intoxication ( hyponatremic encephalopathy )
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Signs and symptoms
Somatic symptoms Psychiatric symptoms Nausea/vomitting Headache Confusion Delirium Ataxia Seizure Coma Death
Agitation Irritability
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Signs and symptoms
Chronic hyponatremia
ataxia/ fall
subtle cognitive impairment
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diagnosis
No diagnostic standard
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Measurement
Biological measure Urine specific gravity Diurnal weight gain Urine osmolarity
Behavioral measure
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Differential diagnosis
•Diuretics(renal loss)•Diarrhea (extra renal
loss)
hypovolemic
•PIP•SIADH•Hypothyroid
euvolemic
•CHF•Cirrhosis•Nephrotic syndrome,renal
failure
hypervolemic
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Management
Identify risk Multidisciplinary approach Biopsychosocial approach
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Multidisciplinary approach
•Differential diagnosis•Treat
hyponatremia,medications
แพทย์
•Evaluate self-care•Water restriction,educationพยาบาล
•Evaluate psychological function
•Behavioral interventionนักจติวทิยา
•Evaluate social function•Discharge planning,care
giverนักสงัคม
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Treatment
Acute treatment
Long-term treatment
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Acute treatment
Water restriction Increase renal free-water excretion Na+ replacement Supportive treatment Symptomatic treatment
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Acute treatment
Fluid restriction Diuretics Salines -- 3%NaCl
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Goal of acute treatment
1. symptoms are abolished
2. safe plasma Na+ ( > 120mmol/l)
3. not more than 10-12 mmol/l/day
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Long-term treatment
Salt -added diet Medications Voluntary water restraint Involuntary water restriction
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Medications
Lithium Phenytoin Naloxone Propanolol Enalapril Clonidine Vasopressin receptor antagonist Clozapine Risperidone
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Behavioral approach
Relaxation Stimulus control Self-Monitoring
distract / substitute Coping skill Reinforcement